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Around the Block.
Minichiello T. AHRQ WebM&M [serial online]. March 2005.
Despite the admission form's warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both and becomes permanently paralyzed.
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Resource Type
Commentary
Setting of Care
Operating Room
Target Audience
Physicians
Nurses
Clinical Area
Anesthesiology
Surgery
Safety Target
Anticoagulants
Postoperative Surgical Complications
Error Types
Noncognitive Errors ("Slips & Lapses")
Approach to Improving Safety
Reminders
Communication between Providers
Forcing Functions
Computerized Provider Order Entry (CPOE)
Residents and Fellows
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)